Basic Information
| Provider Information | |||||||||
| NPI: | 1699099937 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN MUIR HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JOHN MUIR MEDICAL CENTER WALNUT CREEK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 TREAT BLVD | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945972142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259473336 | ||||||||
| FaxNumber: | 9259412236 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 YGNACIO VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945983122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259393000 | ||||||||
| FaxNumber: | 9259412236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2010 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | KENDALL | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9259393000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 05D0680025 | CA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | ZZZA07032 | 01 | CA | BLUE SHIELD | OTHER | ZZR00180F | 05 | CA | MEDICAID | HSP40180F | 01 | CA | MEDICAL OUTPATIENT | OTHER | 050180 | 01 | CA | BLUE CROSS | OTHER |